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Received: 29 June 2021    Revised: 18 September 2021    Accepted: 5 November 2021

DOI: 10.1111/jan.15110

ORIGINAL RESEARCH: EMPIRICAL

R E S E A R C H – ­ Q U A L I TAT I V E

Improving patient-­centred care through a tailored intervention

addressing nursing clinical handover communication in its
organizational and cultural context

Laura J. Chien1  | Diana Slade1  | Maria R. Dahm1  | Bernadette Brady1 |

Elizabeth Roberts2 | Liza Goncharov1 | Joanne Taylor3,4 | Suzanne Eggins1  |
Anna Thornton3,5

1
Institute for Communication in Health
Care, College of Arts and Social Sciences, Abstract
The Australian National University,
Aims: To increase the quality and safety of patient care, many hospitals have man-
Canberra, Australian Capital Territory,
Australia dated that nursing clinical handover occur at the patient's bedside. This study aims to
2
St Vincent’s Hospital Sydney, Sydney, improve the patient-­centredness of nursing handover by addressing the communica-
New South Wales, Australia
3
tion challenges of bedside handover and the organizational and cultural practices that
St Vincent’s Health Network Sydney,
Sydney, New South Wales, Australia shape handover.
4
Nursing Research Institute, St Vincent’s Design: Qualitative linguistic ethnographic design combining discourse analysis of ac-
Health Network Sydney, St Vincent’s
tual handover interactions and interviews and focus groups before and after a tailored
Hospital Melbourne and Australian
Catholic University, Sydney, New South intervention.
Wales, Australia
5
Methods: Pre-­intervention we conducted interviews with nursing, medical and al-
Australian Catholic University, Sydney,
New South Wales, Australia lied health staff (n = 14) and focus groups with nurses and students (n = 13) in one
hospital's Rehabilitation ward. We recorded handovers (n = 16) and multidisciplinary
Correspondence
Laura J. Chien, Institute for team huddles (n = 3). An intervention of communication training and recommenda-
Communication in Health Care, College of tions for organizational and cultural change was delivered to staff and championed
Arts and Social Sciences, The Australian
National University, Canberra, Australian by ward management. After the intervention we interviewed nurses and recorded
Capital Territory, Australia. and analyzed handovers. Data were collected from February to August 2020. Ward
Email: laura.chien@anu.edu.au
management collected hospital-­acquired complication data.
Funding information Results: Notable changes post-­intervention included a shift to involve patients in bed-
This research was supported by funding
from the Geoff and Helen Handbury side handovers, improved ward-­level communication and culture, and an associated
Foundation and St Vincent's Curran decrease in reported hospital-­acquired complications.
Foundation.
Conclusions: Effective change in handover practices is achieved through communi-
cation training combined with redesign of local practices inhibiting patient-­centred
handovers. Strong leadership to champion change, ongoing mentoring and reinforce-
ment of new practices, and collaboration with nurses throughout the change process
were critical to success.

This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in
any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made.
© 2021 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.

J Adv Nurs. 2022;78:1413–1430.  |

wileyonlinelibrary.com/journal/jan     1413
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1414      CHIEN et al.

Impact: Ineffective communication during handover jeopardizes patient safety and

limits patient involvement. Our targeted, locally designed communication interven-
tion significantly improved handover practices and patient involvement through the
use of informational and interactional protocols, and redesigned handover tools and
meetings. Our approach promoted a ward culture that prioritizes patient-­centred care
and patient safety. This innovative intervention resulted in an associated decrease in
hospital-­acquired complications. The intervention has been rolled out to a further five
wards across two hospitals.

KEYWORDS
clinical handover, communication, discourse analysis, ethnography, nursing, organizational
development, patient safety, patient-­centred care

1  |  I NTRO D U C TI O N communication risks are ever-­present. Ineffective communication

Ineffective communication is a major cause of adverse events in hospitals
around the world (Slawomirski et al., 2017; World Health Organization,
2013), resulting in patient harm and death (Garling, 2008) and triggering
patient complaints (Taylor et al., 2002). One of the most ubiquitous, sig-
nificant and problematic aspects of communication in hospitals is clini-
cal handover, the transfer of responsibility and accountability for patient
care between health professionals (Australian Medical Association,
2006). Inadequate handover communication is a key contributing factor
to patient harm, with 80% of adverse events involving miscommunica-
tion during handover (Joint Commission International, 2018).
Improving handover communication to reduce adverse events
has been a longstanding international policy imperative (Australian
Commission on Safety and Quality in Health Care, 2012; Catalano, 2006;
World Health Organization, 2007). Initiatives have included a shift to-
wards patient-­centred approaches to care, prompting many hospitals to
move handover from staff-­only areas to the patient's bedside. However,
analysis of bedside handovers shows that many nurses struggle with the
complex communicative demands of interactions in which they must
simultaneously manage the informational and interactional aspects of
this crucial point of transition in patient care (Della et al., 2020; Eggins &
Slade, 2016a; Eggins et al., 2016). Although communication training can
help nurses to conduct effective bedside handovers (Slade et al., 2018;
Snyder & Engström, 2016; Tobiano et al., 2018), training alone is unlikely
to result in sustained change to handover practices. Research suggests
a more effective approach to practice change is integrating training into
broader institutional change tailored to the local context—­the organi-
zational environment, culture and individuals (Dorvil, 2018; McMurray
et al., 2010). Linguists argue that this local context should include the
challenges and demands of actual communication practices during han-
dover (Eggins & Slade, 2016a).
1.1  |  Background
The fact that clinical handovers are typically delivered verbally
under time pressure and in far from ideal environments means
during handover can result in unstructured handovers that may
contain inconsistent, irrelevant or repetitive information (Manias
et al., 2015; Spooner et al., 2016). Inaccurate or incomplete infor-
mation is a potential safety issue, especially when clinicians do not
adequately explain the reasons for their decisions (Eggins et al.,
2016). Handovers can be monologic, lacking meaningful interac-
tion between clinicians and/or with patients, and disciplinary hier-
archies can mean that incoming staff are reluctant to ask questions
that could clarify ambiguities or omissions (Eggins et al., 2016). Poor
quality written documentation and the lack of an explicit transfer of
accountability and responsibility can hinder continuity of care (Blair
& Smith, 2012).
In Australia, failures in clinical handover have been identi-
fied as a major cause of preventable harm to patients (Australian
Commission on Safety and Quality in Health Care, 2012). For over a
decade the Australian Commission on Safety and Quality in Health
Care (ACSQHC) has been working to improve clinical handover
(Australian Commission on Safety and Quality in Health Care, 2010).
Standard 6 of the ACSQHC’s National Safety and Quality Health
Service Standards provides criteria for effective communication
to ensure safe patient care (Australian Commission on Safety and
Quality in Health Care, 2017). For safe and effective handovers,
the ACSQHC advocates (1) using structured handover tools such as
the ISBAR protocol (Identify, Situation, Background, Assessment,
Recommendation) to provide a framework for communicating the
minimum information content (Australian Commission on Safety
and Quality in Health Care, 2019a); and (2) prioritizing bedside han-
dovers to support patient involvement (Australian Commission on
Safety and Quality in Health Care, 2019b).
Structured handover tools help standardize information pro-
vided in handover. Two integrative reviews considering structured
tools in nursing handover concluded that their use can enhance
the handover process, including through improving communica-
tion skills, enhancing reliability of information transfer and fos-
tering critical thinking (Anderson et al., 2015; Bakon et al., 2017).
Systematic reviews on the impact of structured handover tools on
patient safety found evidence that using tools like ISBAR could

CHIEN et al.
improve patient safety by reducing communication errors such
as omissions and inaccuracies (Bukoh & Siah, 2020; Müller et al.,
2018).
Complementing the need to make handovers structured is
the equally important requirement that handovers be inclusive.
In theory, bedside handover is an expression of a patient-­centred
approach to care, recognizing a patient's right to participate in
their health care. Bedside handovers can facilitate communica-
tion between nurses and patients, fostering the nurse–­p atient re-
lationship and increasing nurse and patient satisfaction (Gregory
et al., 2014; Mardis et al., 2016; Tobiano et al., 2018). Including
patients in handover helps them stay informed about their con-
dition and care plan, and encourages shared decision-­m aking
(McMurray et al., 2011). Patient inclusion can also improve patient
safety as patients can contribute information about their care and
progress, correct errors, provide missing information and answer
questions (McMurray et al., 2011; Tobiano et al., 2018). Bedside
handovers have been associated with decreased patient falls and
medication errors (Sand-­J ecklin & Sherman, 2013), and increased
completion of certain nursing care tasks and documentation (Kerr
et al., 2013).
However, simply conducting handover at the bedside does not
guarantee patient inclusion. One study of over 500 bedside nurs-
ing handovers found patients were actively involved in fewer than
half (Chaboyer et al., 2010). Actively involving patients in handover
depends not only on proximity, but also on whether nurses’ commu-
nication practices foster patient engagement in the process (Dahm
et al., 2022; Eggins & Slade, 2016a). Thus, nurses can benefit from
training that provides them with the communication skills required
to include patients in handover (Anderson et al., 2015; Drach-­Zahavy
& Shilman, 2015; Tobiano et al., 2018). This study aims to improve
the patient-­centredness of nursing handover by addressing the com-
munication challenges of bedside handover and the organizational
and cultural practices that shape handover.
2  |   TH E S T U DY
2.1  |  Aim
The aim of this qualitative study was to improve the patient-­
centredness of nursing clinical handover in a targeted ward by devel-
oping, delivering and evaluating an intervention that addressed both
the communication challenges of bedside handover and the range
of situated practices that enabled and constrained patient-­centred
communication during handover.
2.2  |  Design
The research team applied a qualitative methodology combining
ethnographic and discourse analytic approaches (Eggins & Slade,
2012, 2016a; Eggins et al., 2016; Halliday & Matthiessen, 2004) to
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      1415
analyze actual nursing handovers, interviews and focus groups pre
and post a tailored intervention. Our qualitative study aligns with the
principles of the capability, opportunity, motivation and behaviour
(COM-­B) model (Michie et al., 2011). The COM-­B model describes
how a person's capability (physical and psychological) and opportu-
nity (social and environmental) influence motivation (reflective and
automatic) to enact a behaviour. It is a useful framework for consid-
ering barriers to desired behaviours (e.g. patient-­centred handover
practices) and designing interventions to address these. Qualitative
evaluation is recognized as a way of evaluating the implementation
of nursing interventions and improvements, particularly when inter-
ventions occur in natural settings (Rørtveit et al., 2020). Previous
research on communication in hospital emergency departments
(Pun et al., 2017; Slade et al., 2015) and clinical handover (Eggins
et al., 2016) has demonstrated the effectiveness of our approach.
The multidisciplinary research team was led by an applied linguist
and included nurse–­researchers, nurses and linguist research assis-
tants (all female).
2.3  |  Sample and participants
The study was conducted in the Rehabilitation Ward of a New South
Wales metropolitan teaching hospital as part of a larger multi-­site
study across three affiliated hospitals. The Rehabilitation Ward is
a 22-­bed inpatient ward specializing in care for patients with neu-
rological, orthopaedic or musculoskeletal conditions. The ward has
28 nurses (16 full-­time, 12 part-­time), 5 medical staff and 18 allied
health (7 full-­time, 11 part-­time) with a varied skill mix and scope of
clinical practice (see Table 1).
Hospital management selected this ward for the study follow-
ing persistent difficulties in implementing hospital handover policy.
This policy mandated the use of ISBAR to ensure the most important
information is handed over in a structured format; and at least one
bedside handover in a 24-­h period to facilitate the transfer of patient
care needs from one shift to the next and provide an opportunity
for patient and carer participation in handover. The policy also stip-
ulated that during bedside handover the nurse on the outgoing shift
must:
-­ introduce the patient to the oncoming shift nursing staff and
introduce the nurse to the patient
-­ focus communication on patient care needs
-­ facilitate discussion on patient care concerns, condition changes
and changes in proposed management
-­ ask the patient if they have any questions or comments
-­ invite the patient to confirm or clarify information
-­ refer to relevant charts, care plans or tools during bedside
handover.
Nurses had only received an online ISBAR training module to sup-
port them to meet these requirements. The team also considered
other ward handover practices relevant to the effectiveness of
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1416      CHIEN et al.

TA B L E 1  Rehabilitation Ward staff

Staff Full-­time Part-­time

Nursing
Registered Nurses including Nursing Unit Manager, Clinical Nurse 13 8
Educator, Care Coordinator and Clinical Nurse Specialist
Enrolled Nurses 3 3
Assistants in Nursing 0 1
Medical
Consultants, Senior Registrars, Resident Medical Officers 5 0
Allied health
Physiotherapists, Occupational Therapists, Dieticians, Social 7 11
Workers, Speech Pathologists, Clinical Neuropsychologists

Phase 1 Phase 2 Phase 3

Pre-intervention Intervention Post-intervention
February 2020 June 2020 August 2020

• Interviews and focus groups

with nursing, medical and
allied health staff and
nursing students.
• Non-participant observations
and recordings of huddles
and nursing handovers.
• Thematic analysis of
interviews and focus groups,
and linguistic analysis of
handover events to assess
effectiveness of handover
practices and identify those
practices inhibiting handover.
• Implementation of • Interviews with nursing staff.
recommendations, including • Non-participant observations
redesign of the and recordings of nursing
multidisciplinary team handovers.
huddle and nursing handover
sheet. • Thematic analysis of
interviews and linguistic
• Communication in nursing analysis of handovers to
clinical handover training evaluate the intervention.
based on CARE and ISBAR
protocols followed up with
mentoring to reinforce
training.

F I G U R E 1  The research process

nursing handover, in particular the nursing-­led multidisciplinary team
‘huddle’ held each morning to share patient information among nurs-
ing, medical and allied health staff (Clinical Excellence Commission,
2017).
With the assistance of the Nursing Unit Manager (NUM) and
using purposive sampling we recruited nursing, medical and allied
health staff (n = 20) and nursing students (n = 7) for interviews and
focus groups in phase 1, and nurses (n = 6) for interviews in phase
3. Maximum variation strategies were employed to ensure a diverse
sample of participants in terms of clinical roles and level of experi-
ence. Recruitment ceased once we reached thematic saturation and
no new themes were raised in interviews.
Convenience sampling was used to recruit participants for the
recordings of nursing handovers to capture handovers that arose
naturally as a part of the ward's routine. Inclusion criteria were: (i)
clinicians engaged in giving or receiving clinical handover on the
selected ward and willing to provide written informed consent and
participate in the study; and (ii) patients over the age of 16, likely to
be present on the selected ward while their care was handed over,
with the cognitive and physical capacity to give written informed
consent and willing to participate in the study. Patients with a his-
tory of a condition that inhibited their ability to understand the
study were excluded.
2.4  |  Data collection
The study involved three phases: phase 1, pre-­intervention data col-
lection in the nominated ward; phase 2, delivery of the interven-
tion (communication training and organizational and cultural change
recommendations), based on findings from analysis of phase 1
data; and phase 3, collection and analysis of post-­intervention data.
Figure 1 summarizes the research process.
Data were collected between February and August 2020. All
interviews, focus groups and handovers were audio-­ or video-­
recorded and professionally transcribed. Transcripts were not re-
turned to participants for comment or correction. Prior to phase 1,
two members of the research team (DS, LG) provided briefing ses-
sions at the hospital to introduce themselves and inform ward staff
and management about the research.

CHIEN et al.
2.4.1  |  Phase 1: Pre-­intervention
In phase 1 (February 2020), four experienced qualitative researchers
on the team (DS, LG, BB, MD) conducted 15 individual semi-­structured
interviews (ranging between 15 to 75  min; 1 repeat interview) with
nursing (n  =  5), medical (n  =  4) and allied health staff (n  =  5) and 2
focus groups (11 and 26 min) with nursing staff (n = 6) and students
(n = 7) on site. These were designed to elicit insider perspectives on the
problems and challenges with ward handover practices. The interview
schedule (adapted from Eggins et al., 2016) included open-­ended ques-
tions about nursing handover, potential problems and their impact on
patient safety and quality of care, the skillset and patient information
required for effective handover, the purpose and conduct of the mul-
tidisciplinary team huddles and the flow of patient information among
team members. Four members of the research team (DS, LG, BB, MD)
also observed and audio-­recorded 16 routine nursing handovers and
3 huddles. Thematic sketches of nurses’ positioning and movements
during handover and materials (patient brochures and handover
sheets) were also collected, de-­identified and analyzed.
2.4.2  |  Phase 2: The intervention
Based on phase 1 findings, in phase 2 (June 2020) the team pre-
sented ward management with an intervention. This consisted of
18  recommendations to improve ward handover practices, includ-
ing the delivery of a communication training module to address the
interactional and informational risks identified in the phase 1 data. In
June 2020, the applied linguist and nurse–­researcher delivered 2-­h
communication in nursing clinical handover training sessions to 35
people, including nurses, ward-­ and hospital-­level management and
a small group of allied health and medical staff. The evidence-­based
training aimed to (1) improve the informational dimension of hando-
ver through use of ISBAR to structure both the handover sheet and
the verbal handover; and (2) improve the interactional dimension
of handover through use of the Connect, Ask, Respond, Empathise
(CARE) protocol (Eggins & Slade, 2016b). The training explored with
nurses the rationales for and advantages of bedside handovers so
they recognized the value of this workplace practice. It also helped
nurses develop collaborative strategies to address problems in hand-
over delivery and communication identified in phase 1, including
handling confidential information. The training featured video re-­
enactments of handovers based on audio/video recordings of actual
nurse handovers in Australian hospitals. During training nurses ap-
plied their knowledge of the ISBAR and CARE protocols to critique
these re-­enactments and participated in handover role-­plays to gain
the communication skills required to conduct safe and effective bed-
side handovers. The communication training was well received by
participants, with 94% of participants who completed an evaluation
form rating it on a scale of 1 to 6 as ‘6 very useful’.
In parallel with the training, the NUM oversaw implementa-
tion of a suite of recommendations made by the research team.
Recommendations covered handover events, handover tools,
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      1417
cultural change and mentoring, and handover policy (Appendix S1).
A key recommendation on handover events was the redesign of the
multidisciplinary team ‘huddle’. In collaboration with staff, this be-
came a short risk-­focused safety meeting and a template was devel-
oped to structure the meeting around patient safety risks. The NUM
and the Clinical Nurse Educator facilitated a staff working group to
redevelop the nursing handover sheet to reflect the ISBAR protocol.
Throughout the intervention, the NUM and Clinical Nurse Educator
were present on the ward to observe staff conducting handover.
They provided real time mentoring to reinforce training in the ISBAR
and CARE protocols, listened to staff feedback on the intervention
and supported staff through the transition to bedside handover. The
Clinical Nurse Educator spent additional time mentoring new and
less experienced nurses on using the dual protocols to conduct bed-
side handover. New staff were also given the opportunity to observe
and conduct bedside handovers while supernumerary.
2.4.3  |  Phase 3: Post-­intervention
In phase 3 (August 2020), the team returned to the ward 6  weeks
after the intervention to assess its impact on ward handover practices
and attitudes. Two members of the research team (DS, JT) conducted
six individual semi-­structured interviews (ranging between 18 and
51 min) with nursing staff (n = 6), asking them to reflect on the training
and associated changes to ward culture and handover practices. We
observed, recorded and analyzed three nursing handovers.
2.5  |  Ethical considerations
Ethics approval was granted by the Human Research Ethics
Committee of the participating hospital. Participants were given a
verbal and written explanation of the aims of the research, a state-
ment of their right to choose to participate or not and an assurance of
confidentiality. All participants provided written informed consent.
2.6  |  Data analysis
All audio/video-­recorded data were transcribed, de-­identified and
assigned a code or pseudonym for analysis. The interview and focus
group data were analyzed using Braun and Clarke’s (2006) six-­phase
approach to thematic analysis. Two members of the research team
(MD, LC), one of whom had not been involved in data collection and
brought a fresh perspective to the analysis, immersed themselves
in the data through repeated reading, noting initial ideas for coding.
They then generated initial data-­driven codes independently keep-
ing code books in Microsoft OneNote. Together they sorted codes
into potential themes and used the principle of constant compari-
sons to ensure coherence with the coded extracts and the dataset as
a whole. This meant potential themes were iteratively reviewed and
refined. The data were managed in Microsoft Excel.
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1418      CHIEN et al.

The audio-­r ecorded nursing handover data were analyzed lin-
guistically by DS, MD, LC, BB drawing on tools from functional
linguistics, in particular, Systemic Functional Linguistics (Eggins,
1994; Halliday & Matthiessen, 2004). We analyzed the informa-
tional dimension of handover (how nurses organize and express
clinical information about the patient) using an adapted version
of the ISBAR protocol. The ISBAR protocol (Figure 2) re-­g losses
the ISBAR elements in nursing-­o riented terms to help nurses
transfer patient information in a logical, coherent sequence. We
analyzed the interactional dimension of handover (how nurses
interact with patients) using the CARE communication protocol
developed and validated by DS and her team (see Eggins & Slade,
2016b; Pun et al., 2019). The CARE protocol (Figure 3) provides
nurses with strategies to improve the quality of interaction with
the patient to support patient inclusion and safety. By identify-
ing the informational and interactional structures according to
the ISBAR and CARE communication protocols, we could evalu-
ate whether the handovers fulfilled their dual goals of communi-
cating the minimum information content in a structured manner
and enabling patient inclusion. By triangulating findings from the
thematic analysis of interview and focus group data with observa-
tions, linguistic analysis of interactions and nursing documentation,
we were able to combine information about what people said they
did with what they actually did (Eggins et al., 2016; Mays & Pope,
1995).
2.7  |  Rigour
Researchers employed several strategies described by Creswell and
Creswell (2017) to ensure qualitative validity and reliability of the
study. Strategies to confirm validity included triangulation of data
collected through multiple sources (interviews and focus groups,
observations, interactions and documentation) and member check-
ing to confirm the accuracy of our findings. We conducted a follow-
­up briefing with a senior nurse to discuss preliminary findings and
co-­construct several recommendations. Additionally, we engaged
with ward management to discuss draft findings and verify recom-
mendations. Strategies to confirm reliability included checking ver-
batim transcripts against recordings for accuracy prior to analysis,
cross-­checking codes­ derived independently and, for the linguistic
analysis, resolving disputes over interactional and informational
categories though group discussion. In terms of the communication
training, pre­ and post ­studies evaluating the impact of the CARE
and ISBAR protocols have shown their efficacy in improving nurse
understanding and practice of bedside handover (Pun et al., 2019;
Slade et al., 2018). Finally, the study is reported in accordance with
Standards for Reporting Qualitative Research (O’Brien et al., 2014)
and the Consolidated criteria for reporting qualitative research
(Tong et al., 2007; Supplementary Material).
3  |  FI N D I N G S
3.1  |  Phase 1: Pre-­intervention findings
Analysis of phase 1 ethnographic observations, interviews and focus
groups and audio-­recorded handover interactions revealed short-
comings in handover delivery and communication. The researchers
found that these communication issues were directly shaped and
constrained by systemic factors in the organizational and cultural
context of the ward (Figure 4).

STAGE NAME AIM OF EACH STAGE

I Introduce & To introduce yourself by stating the role

Identify you have played in this patient’s care.
To clearly and accurately identify and
locate the patient.

S Situation To explain the patient’s presenting

condition.

B Background To hand over the patient’s medical and

social background relevant to this
admission.

A Assessment & To succinctly describe the patient’s

Actions general condition, clinically and
behaviourally, during your shift.
To state what you have done for the
patient on your shift.

R Recommendations To explain the treatment plan for this

& Readback patient. F I G U R E 2  The ISBAR protocol
To clearly hand over accountability and (Identify, Situation, Background,
responsibility for ongoing care tasks. Assessment, Recommendation) adapted
for nursing handovers
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CHIEN et al.       1419

F I G U R E 3  The CARE protocol

STAGE NAME AIM OF EACH STAGE
(Connect, Ask, Respond, Empathise) for
bedside nursing handovers C Connect Greet the patient.
Introduce yourself and the team.
At the end, thank the patient and say
goodbye.

A Ask Find out what the patient knows.

Find out what your colleagues know.

R Respond Listen and react to whatever the patient

and your colleagues say.

E Empathise Respect sensitivities and be aware of

the patient’s feelings.

F I G U R E 4  The impact of systemic

factors on handover delivery and
Negative impact on handover quality
communication

Organisational Problems in Cultural

barriers to handover delivery barriers to
handover and communication handover

• Lack of awareness of hospital • Inappropriate handover • Culture of non-accountability

and national policy and
guidelines
• Ritualised but ineffective
handover routines
• Practical organisational
constraints on compliance
with guidelines
location
• Lack of patient involvement
• Lack of information structure
of nurses
• Lack of valuing of and
commitment to patient-
centred care
• Hierarchical constraints
against speaking up

3.1.1  |  Problems in handover delivery and
communication
Inappropriate handover location
Despite hospital guidelines mandating bedside handover, most
handovers occurred in the corridor or just inside the patient's room,
not at the bedside. Nurses stated strong concerns about confiden-
tiality, which they said hampered their ability to conduct handover
at the bedside in earshot of other patients. One nurse stated that
nurses were ‘always thinking that confidentiality is an issue’ and
were uncertain about ‘what can and can't I say in front of the patient’
(Registered Nurse [RN] 2). How nurses perceived patient preference
also determined handover location. Nurses felt that some patients
found it ‘off-­putting to have a bedside handover’ because they over-
heard what was being said about them and other patients (RN focus
group 2).
Lack of patient involvement
The nurses’ preference to conduct handover in the corridor meant
that patient involvement in handover was low and often limited to a
greeting. Nurses did not see handover as an opportunity to involve
patients in their care, but rather focused on the quick transfer of
information as described by this nurse:
Because our patients are here months and months
[…] we know them pretty well. It’s important for the
handover just to tell us what changes, any medication
changes … […] Just come to the main points. That’s
what we are trying to do. So that way we’re not wast-
ing time. So the handover gets finished faster. (RN
focus group 2)
Table 2, ‘Rebecca’, is representative of the naturally occurring
handovers recorded in phase 1. In this example, an incoming nurse
walks into Rebecca's room to greet her, before returning to the cor-
ridor for handover. Despite being in earshot, the nurses talk about
Rebecca as if she is not present, referring to her in the third per-
son (‘She is eating, drinking well’; ‘her mobility is poor’) or omitting
the pronoun altogether to talk only of her body parts and processes
(‘didn't open bowels’).
Even when nurses gave handover at or near the bedside, patients
were rarely involved. The outgoing nurse rarely introduced patients
to the incoming team and rarely told them which incoming nurse
would be looking after them. One nurse commented on the lack
of patient involvement in bedside handover suggesting that some
nurses had not changed their communication during handover to fa-
cilitate patient inclusion:
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1420      CHIEN et al.

I know bedside handover is a good idea, but I notice
often we older nurses are still practicing the same [at
the bedside] as if we were [giving handover] out of
the room. (RN3)
The transcript in Table 3, ‘Jim’, shows that the patient's involvement
is limited to a greeting, despite the fact that the handover is conducted
at the bedside. The outgoing nurse does not introduce Jim to the in-
coming team or invite him to contribute. Several discourse features hin-
dered patient involvement. The outgoing nurse's repeated use of the
judgmental term ‘refuse’ (turns 3 and 5) implies that Jim is not being
cooperative. Her use of reported speech in turn 3 (‘He said he's gonna
shower in the afternoon’) implies that Jim may not be telling the truth.
The remark ‘Always say’ (turn 4) appears to imply a claim such as ‘Jim/
patients always say that’, which Jim may perceive as critical.
Relatives were also rarely invited to participate in handover. When
they did contribute, often uninvited, nurses often did not acknowledge
or respond to their comments with rapport or empathy. In Table 4,
‘Dolores’, an extract from a naturally occurring bedside handover, al-
though Dolores’ son tries to contribute information about his mother's
loss of consciousness (turns 31 and 33), the outgoing nurse speaks
over his attempts (turns 32 and 34), before shutting him down both
physically (turn 35) and verbally (turn 36) to continue the handover.
Later, when Dolores’ son talks about his personal experience with his
mother's condition (turns 39, 41, 43, 45 and 47), the outgoing nurse
interrupts to continue handover (turns 44, 46 and 48). Her failure to
acknowledge the son's contribution shows a lack of respect for his ex-
perience and the valuable clinical information this represents.
Lack of information structure
Despite hospital guidelines mandating the use of ISBAR, there
was little adherence to an ISBAR-­d erived minimum dataset. The
ward's handover sheet did not reflect the ISBAR structure. Nurses
described the information provided in handover as ‘inconsistent’
and ‘not really following ISBAR’ (RN2). Nurses were aware of the
potential risks to patient safety, acknowledging that this lack of
structure meant that ‘important things get missed’ leading to ‘pa-
tient safety incidents […] like falls and not actually handing over
what we are doing about the falls risk patients’ (RN2).
The lack of a protocol to present information systematically is ev-
ident in two naturally occurring handovers—the ‘Rebecca’ (Table 2)
and ‘Jim’ (Table 3) handovers. In these examples, the ISBAR stages
Identify and Situation are minimal; the outgoing nurses focus on pro-
viding Assessment. As one student nurse said, nurses ‘hand over what
happened during that shift and that's about it’ (Student nurse, focus
group). In both handovers the Background stage is not covered, nor
are any Recommendations offered. These were typical omissions in
pre-­intervention handovers. Student nurses expressed concern about
the practice of omitting the patient's background and leaving ‘it to us
to read all about that’ in the medical file (Student nurse, focus group).
The practice of omitting the Recommendation stage poses risks to
continuity of care as the care plan is not summarized and lines of re-
sponsibility and accountability for patient care tasks are left implicit.
3.1.2  |  Systemic issues related to ward organization
and nursing culture
As the examples in Tables 2–­4 presented above show, there was a
marked disconnect between nursing clinical handover policy and
actual ward practice. Analysis of observations, documentation and
interview data suggested that this apparent disregard of handover
guidelines was the result of systemic issues related to organizational
and cultural factors in the ward context.

TA B L E 2  ‘Rebecca’ corridor handover

Turn Speaker Talk ISBAR

1. Outgoing N: That's Rebecca. (Rebecca's room) I

2. Incoming N1: (5 sec) [quietly in background] (Hi Rebecca,
how are you?)
3. Incoming N2: She's in Room 9, isn't it?
4. Incoming N2: Rebecca==She's in Room 9.
5. Outgoing N: ==Rebecca. 33 years, female, diagnosis I
(HD) upper-­[very quietly] ( ) we give
her shower so we give her wash and her A
mobility is four wheel walker standby assist
and whole day she just ( ) to want to stay
in her bed. She is eating, drinking well. We
feed her [combined] with medication, obs
stable, normal.
6. Incoming N1: Thank you.
7. Outgoing N: Oh, and didn't open bowels. A
8. Incoming N1: [quietly] That's her.

Note: Key: (words in parentheses) indicates transcriber's doubt; (  ) impossible to transcribe; ==

signals overlap with another speaker.
Abbreviation: ISBAR, Identify, Situation, Background, Assessment, Recommendation.

CHIEN et al.
TA B L E 3  ‘Jim’ bedside handover
Turn Speaker
1. Incoming N1:
2. Patient (Jim):
3. Outgoing N:
4. Nurse:
5. Outgoing N:
6.
Note: Key: ::: elongated vowel sound; … short pause.
Abbreviation: ISBAR, Identify, Situation, Background, Assessment, Recommendation.
Organizational barriers to handover
Lack of awareness of hospital and national policy and guidelines. There
was little evidence that ward nurses were familiar with national
(Australian Commission on Safety and Quality in Health Care,
2017) and state (Clinical Excellence Commission, 2019) handover
guidelines or hospital handover policies. Nurses did not refer to
these in interviews or focus groups.
Ritualized but ineffective handover routines. The nursing-­led
multidisciplinary team huddles did not follow the recommended
structure or content described by the Clinical Excellence Commission
(2017) policy. The meetings followed a patient-­by-­patient sequence
with the presenting nurse sometimes providing information that
was irrelevant to other disciplinary groups. As a result, the meetings
were lengthy, inefficient and failed as a means of communicating
critical patient information among the multidisciplinary team.
There were no formal processes to ensure the ward nurses were
informed about relevant patient information for their shift. Rather,
one nurse described how the team leader attending the huddle
would ‘have a chat’ (RN3) with the ward nurse to pass on relevant
updates. The huddles appeared to have become a ward ritual,
recognized by participants as often tedious and inadequate but
persisting unchallenged. As one nurse noted, ‘With multidisciplinary
team huddles there's no structure there and there is inconsistency,
information gets missed, there's lots of gaps in there’ (RN2).
Practical organizational constraints on compliance with guidelines.  were not made aware of handover times nor invited to participate.
Nurses often could not conduct handovers consistent with the
hospital's policy because despite being outlined in guidelines,
handovers rarely started on time, ran longer than recommended and
were frequently interrupted.
|
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      1421
Talk ISBAR
Ji:::m, Hello Jim. Hi, how are you?
( )
Another handsome man. ( ) pleasant. Uh so
Jim is 80 years old. He came with a total hip IS
replacement on eighteenth of eleventh …
2019. Uh his mo-­his mobility is independent. A
He refuse shower. He said he's gonna shower
in the afternoon- early afternoon.
[quietly] ( ) always say.
What else? He walking, he refused Coloxyl A
and Senna this morning he said, because he
opened the bowel yesterday. He is walking
independently. His observations is good, so
he settled. Aren't you?
[No audible response from patient. The
outgoing nurse moves straight onto handing
over the next patient in the same manner]
Cultural barriers to handover
Culture of non-­accountability of nurses. Accountability and res­
ponsibility for patient care were not clear, allowing for some ‘buck
passing.’ Nurses indicated that they did not see themselves as
responsible or accountable for all patients on the ward. One nurse
noted that there was a tendency to ‘pass the buck to the doctor
or the allied health clinicians and say, “Patient has this. Doctors
informed. Full stop”’ (RN2) as if to excuse themselves from further
responsibility for care. Another nurse spoke of how this lack of
accountability and responsibility for patient care negatively affected
communication between staff:
It’s kind of the culture of nurses to say, “I don’t know
anything about it”. [So it’s important to] keep the
communication open between different people who
come to your unit, you can’t shut them down by say-
ing … “I’ve just been to lunch. I’ve no idea”. It’s not
good communication. (RN1)
Because patient allocation occurred after the handover had been deliv-
ered, responsibility and accountability were not transferred directly to
the incoming nurse responsible for each patient.
Lack of valuing of and commitment to patient-­centred care. In the
interviews and focus groups, no nurses spoke about the many
benefits of a patient-­centred approach to care. Patients and carers
Some nurses did, however, acknowledge that they should be
‘including the patient during the whole process’ (RN8), suggesting a
general awareness of the issue of patient inclusion in handover. Such
comments highlighted a need for training in how to communicate
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1422      CHIEN et al.

TA B L E 4  ‘Dolores’ bedside handover

Turn Speaker Talk ISBAR

30. Outgoing N: So I quickly took her a few steps to the bed and A
soon she says to me, that she's not feeling good. So
she starts to lean on me and then she just stopped
talking. So lost-­lost consciousness==
31. Patient's son: ==yes yeah==
32. Outgoing N: ==about 10 seconds or something. ==So I just A
quickly…
33. Patient's son: ==She has bla-­she has blackouts.
34. Outgoing N: ==Blackouts, ==yeah.
35. Patient's son: ==yeah == we've ( ) yeah
[Outgoing nurse turns her back on son and husband]
36. Outgoing N: ==So I just quickly put her back to bed and I was A
calling [nurse manager's name] because no one was
around, I was like shouldn't I just==
37. Patient ==no one comes
(Dolores):
38. Outgoing N: ==call Code Blue. But lucky Dr [doctor's name] was B
here, so she came to assess her. She says, pretty
normal common for her. So actually doctor made a
plan for her, said if she's having these pass out, like
… doesn​'t-­like her-­herself doesn't come back in one
minute, we need to call Code Blue, otherwise we just
call her, you know, shake her. Because ==she…
39. Patient's son: ==Yeah, she's come to within about a minute. You
know. If you-­
40. Outgoing N: Yup
41. Patient's son: If you put her on her back
42. Nurses: ==Mm-­hm
43. Patient's son: and put a pillow, she'll sort of …
44. Outgoing N: Yep, ==actually after we…
45. Patient's son: ==It's usually less than a minute.
46. Outgoing N: Yeah, after we== put her back to bed …
47. Patient's son: ==She can't remember anything. ==She can't
remember doing it.
48. Outgoing N: ==she ( ) and then she starts the talking. She still says A
she's not feeling well, but we tilt the bed down and we
re-­re-­check her blood pressure and then actually her
blood pressure went up very high. (…)
49. [Outgoing nurse continues assessment]

Abbreviation: ISBAR, Identify, Situation, Background, Assessment, Recommendation.

inclusively, negotiate the presence of family and carers, and manage
their input during handover.
Hierarchical constraints against speaking up. Nurses also reported
internal hierarchies that made it difficult for junior and student
nurses to speak up about concerns or ask questions. One student
nurse reported feeling alienated by the hierarchical culture:
Then some of them [nurses], I don’t think they like
students, so they just look at us like, to say ‘don’t just
stand there and harass us all day'. (Student nurse,
focus group)
As a result, professional learning opportunities for junior and
student nurses were missed. These students expressed a need
for mentoring and guidance on how they should conduct han-
dover and write in patient medical records. One student nurse
commented on the difficulty of working effectively without
guidance:
Normally the morning shift, most of the nurses they
are really busy because it’s nearly time for the med-
ication and everything. So, no one—­I mean, what’s
going on we don’t know. We have to find out later and
we can’t ask them because they are very busy and we

CHIEN et al.
don’t want to interrupt while they are giving medica-
tion as well. (Student nurse, focus group)
3.1.3  |  Summary of phase 1 findings
Overall, these findings demonstrated the need for an intervention that
combined communication training in bedside handover with a suite
of recommendations designed to create organizational and cultural
change to make bedside handover possible, productive and respected.
3.2  |  Phase 3: Post-­intervention findings
Six weeks after the intervention, the research team returned to the
ward to record interviews and handovers and observe uptake of the
recommendations. This post-­intervention data revealed improve-
ments to handover communication, ward organization and nursing
culture.
3.2.1  |  Changes in handover delivery and
communication
Bedside handover location
Nurses reported that handovers routinely took place at the patient's
bedside rather than in the corridor. Nurses did not mention their previ-
ously strongly held concerns about patient confidentiality; nor held on
to earlier claims that patients did not want bedside handovers. These
findings suggest the training had successfully explained the rationale
for bedside handover and allayed nurses’ concerns. Acknowledging the
benefits of this practice for patients, one nurse commented that pa-
tients now knew ‘the exact nurse who's going to be looking after you
throughout the day. […] whatever question you have, this is the person
for you to answer [ask]’ (RN11). She also remarked that nurses could
now visualize the patient, noting the benefits for providing patient care:
When you’re around the bed, you seem to like just
look on the board behind them, their mobility, the
patient’s face, how they’re sitting, how they’re po-
sitioned, small things like that made a big difference
in terms of how we can look after this patient better,
rather than standing outside not knowing who’s going
to be behind the curtain. (RN11)
Increased patient involvement
Reflecting this deeper appreciation for patient-­centred approaches
to care, nurses actively involved patients in the handover and inter-
acted with them beyond the previously token greetings (discussed
below in the naturally occurring bedside handover in Table 5). Nurses
acknowledged a change in attitude towards patient inclusion in
handover. Nurses felt that the emphasis was ‘now with the interac-
tion with the patients’ (RN9) and this had ‘given the patients that
|
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      1423
opportunity to be a bit more involved in their care planning’ (RN3).
Nurses reflected on the many benefits of involving patients in hand-
over, explaining that they were ‘more up-­to-­date with what's going
on with the patient’ (RN9). They also noted that patients could con-
tribute information about their care, correct errors, provide missing
information and answer questions. One nurse stated that greater in-
volvement ‘gives the patients an opportunity to say, no, that's wrong’
(RN9), while another commented that ‘asking the patient, is there any
concerns? Is there something you want to add?’ (RN11).
Implementation of communication protocols
Analysis of the video-­recorded handovers indicated that the com-
munication training had helped nurses gain communication skills to
manage the interactional and informational issues identified in phase
1. Participants identified the CARE and ISBAR protocols as the most
useful components, commenting that these had helped them struc-
ture their handover interactions:
I like this framework. I see the opportunity to improve
clinical handover in terms of making it more interactive,
including the consumer, empowering the nurses to own
it […] I think it gives them structure, and it gives them
something to reference, a reference point. It’s very
clear about the objectives, about where it fits in with
communicating for safety, where it fits in with team
leader roles, individual nurses’ accountability. (RN2)
Following the training nurses more often sequenced information
in the systematic structure of the ISBAR protocol, thereby providing a
minimum dataset of information for bedside handover. Nurses noted
the importance of restructuring the handover sheet by ISBAR to facil-
itate this change:
Redesigning the handover tool so it supported ISBAR. I
think that was a big thing for them. Previously the han-
dover tool was very messy, it was not structured. (RN3)
The transcript in Table 5, ‘Ruth’, a naturally occurring bedside
handover, exemplifies the changes to communication practices ob-
served in the post-­intervention phase. The nurses apply the CARE
protocol to actively involve Ruth in the handover. The incoming
nurse engages Ruth directly by greeting her (turns 1, 3 and 5), em-
pathically sharing joy in her progress (turns 20 and 22) and having
a conversation while examining her legs (turns 24, 26, 28 and 30).
The outgoing nurse introduces herself and the team (turns 8 and 10)
and encourages Ruth to contribute information frequently (turns
11, 13, 15, 33 and 36). Both nurses demonstrate active listening by
responding to input from Ruth (turns 22 and 28). While the nurses
do address Ruth by her first name, there is still a residue of earlier
practices, with the nurses regularly referring to Ruth using pronouns
‘her’ and ‘she’ rather than addressing Ruth directly with ‘you’, as had
been suggested in the training. In terms of structure, the outgoing
nurse applies the ISBAR protocol to organize the information she is
 |
1424      CHIEN et al.
handing over in a logical sequence, with the exception of the infor-
mation provided at the end to flag a patient safety issue (turns 38 and
40). Each ISBAR stage is covered, although the outgoing nurse does
not seek Readback to ensure shared understanding and clearly hand
over accountability and responsibility for Ruth's ongoing care tasks.
3.2.2  |  Changes to organizational practices and
cultural attitudes
Organizational changes
Team huddle reconceptualised. The multidisciplinary huddle, renamed
the Rapid Risk Meeting, had become an efficient 10-­min meeting that
fulfilled its function of communicating critical information on patient
safety concerns among team members, as noted by this nurse:
I think the Rapid Risk Meeting has seen great bene-
fits. It’s brought the multidisciplinary team together.
[…] It’s risk-­focused, it’s management of the risks,
there’s open discussion between the multidisci-
plinary team, they’re involved in the discussion,
the decisions that come out of that meeting. I think
that’s been a key piece in changing the culture and
bringing that multidisciplinary team engagement
across the floor. (RN3)
This change, combined with the introduction of formal processes
to facilitate the flow of patient information from the Rapid Risk
Meeting to ward nurses, meant that ‘all the team knows who they
have to prioritize and who they have to be careful with the safety
for patients’ (RN10).
Practical changes. The intervention had also prompted considerable
changes to practical dimensions of handover. Patient allocation
occurred before handover so that responsibility and accountability
for care were handed over from the outgoing nurse to an identified
incoming nurse. Changes to ward routines meant that handover
was able to commence on time and did not take longer than 30 min.
Information sheets were displayed around the ward, notifying
patients and carers of the time and purpose of bedside handover
and inviting them to participate.
Changes to nursing culture
The intervention provided the impetus for positive change to aspects
of ward nursing culture. Nurses noted ‘more professionalism’ (RN10)
exhibited on the ward and commented that the training had ‘encour-
aged [them] to be accountable for their shift and the care that they've
provided’ (RN2). This increased sense of professionalism was accom-
panied by the nurses’ increased appreciation of the value of patient-­
centred care. One nurse suggested that patient-­centred care helped
TA B L E 5  ‘Ruth’ bedside handover
Turn Speaker Talk
1. Incoming N1: Hello hello.
2. Incoming N2: We just … we are still waiting for a mask.
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develop the nurse-­patient relationship, stating that it is ‘good for the
patients to know who's looking after them in the afternoon, that famil-
iar face’ (RN9). Another nurse raised the importance of patient-­centred
care in helping patients understand their condition and care plan:
For the patient it is important because they know why
I’m in Rehab and what is the goal that’s set for me. […]
So, they know that this is the plan. […] It improves care
of the patient. (RN10)
The intervention also facilitated a turnaround in the hierarchical
aspects of ward culture that previously alienated junior and student
nurses. After the intervention, nurses embraced a culture of mentoring
and modelling practice to student and junior nurses. Student nurses
were routinely buddied up with nurses to support their professional
development. Nurses articulated the benefits of mentoring inexperi-
enced nurses and modelling handover practice:
If a junior nurse comes along and you have someone
who really supports this framework … it really helps
them lay the foundation … doing it the correct way.
This is the way we do it. I guess they adapt [adopt] it
in their practice. (RN9)
3.2.3  |  Impact on patient outcomes
The hospital routinely collects data from its reporting system to
analyze trends in inpatient falls, hospital-­acquired pressure injuries
and medication errors. As a qualitative study we did not assess the
impact of the intervention on these patient safety measures; how-
ever, the observed improvements to patient outcomes are worth
noting. The monthly average over a 9-­month period following
training and implementation of the recommendations (July 2020
to March 2021) was compared with the monthly average of the
same period over the previous 3 years (July to March in 2017/18,
2018/19 and 2019/20). There was a 48% reduction in inpatient
falls (M = 3.9 vs. 2.0); a 20% decrease in the number of hospital-­
acquired pressure injuries (M = 0.6 vs. 0.4); and a 43% reduction in
medication errors (M = 0.8 vs. 0.4). Following the intervention, the
Rehabilitation Ward went 86 consecutive days without a patient
fall. Prior to this the average rate of patient falls was 4 per month.
Nursing management attributed these improvements in patient
safety, at least in part, to the intervention and its implementation:
It’s communication. It’s all the communication el-
ements coupled with leadership and the [clinical
nursing handover] project is the vehicle. So, with-
out having a vehicle to pin the leadership to, which
was the communication piece, you flounder. […] The
CARE ISBAR
Connect
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CHIEN et al.       1425

TA B L E 5  (Continued)

Turn Speaker Talk CARE ISBAR

29. Ruth: Yes, it's … yep.

30. Incoming N1: ==Okay [nodding] okay, all right. Respond
31. Outgoing N: ==So dressing was due today, and I changed already A
and just to clean with normal saline and–­sorry
normal saline and a (Mepilex border). It is
improving, there is no sloughiness or oozing or
discharging from anything so we'll continue with the R
second daily dressing. Uhm, doctor–­sorry pathology A
lady took some blood this morning and for the
==INR.
32. Incoming N1: ==INR, yep.
33. Outgoing N: So yesterday the blood result was good. So she did A
have some Warfarin with 1.8 INR. Let's see today R
what doctor going to chart it out, you know. But so
far, no other issues. Anything you want to add Ruth? Ask
Any concerns?
34. Ruth: No, no. No concerns.
35. Incoming N1: ==Ah good. Respond
36. Outgoing N: ==Anything you worry, or anything you want to tell Ask
nurses for this afternoon?
37. Ruth: No.
38. Outgoing N: Yeah, the reason why Ruth choose this side bay is B
because it's easier for her to ==go to the toilet, it's
just close by.
39. Incoming N1: ==go to the toilet. Mm.
40. Outgoing N: And before it was stand by assist, but now it is just A
with ==supervision.
41. Incoming N1: ==Supervision. Good good.
42. [Over speaking]
43. Outgoing N: Thank you. Connect
44. Incoming N2: So we'll see you…
45. Outgoing N: All good, my dear. Connect
46. Ruth: Okay, thank you.
47. Incoming N1: Thank you. We'll see you later, Ruth. Connect
48. Ruth: Thank you.

Abbreviations: CARE, Connect, Ask, Respond, Empathise; ISBAR, Identify, Situation, Background, Assessment, Recommendation.

increased communication coupled with the leader-
ship saw an associated reduction in falls, pressure in-
juries and medication errors. (Nurse Manager 1)
3.2.4  |  Key drivers for intervention success
Several key drivers were critical to the success of the intervention in-
cluding strong ward-­level leadership, engaging nurses in the change
process and ongoing support from nursing leadership during the in-
tervention phase and beyond. Leadership at the ward-­level was cru-
cial to take accountability for change and set clear expectations for
nurses. One nurse commented that the NUM had ‘been very good
at setting the agenda, driving it and setting the […] program, [saying]
this is what we want to see’ (RN2). Including nurses to become part
of the change process helped facilitate changes in ward culture and
practice. As RN2 remarked:
I think that engagement with the nursing team where
they’ve been able to be a part of the change from
the start. So we’ve brought them along the journey.
So they participate in the training and then after the
training, there were a lot of discussions […]. That in-
volvement from the start I think has really increased
their engagement. In not only better bedside [project
name] but other things, other changes in the ward. It’s
had a really big cultural, like it’s impacted on the cul-
tural change. (RN2)
 |
1426      CHIEN et al.
The ongoing mentoring and continued reinforcement of the prac-
tice changes were crucial to emphasize management expectations and
consolidate new practices. RN3 commented on the intensive mentor-
ing carried out by the ward's Clinical Nurse Educator:
So the Clinical Nurse Educator for the past few weeks
has been on the floor at 1:30 every day that she’s
been here, following them, observing, giving them
real time feedback. So she’d pull them- you know,
after a handover, she’d tell them what she picked up
on that was good and give them a bit of constructive
feedback as well. (RN3)
4  |   D I S C U S S I O N
This study combined ethnographic and discourse analytic approaches
to analyze handover practices in a local ward context. The research
team made ward-­level recommendations and developed communica-
tion training to address the identified context-­specific organizational,
cultural and communicative challenges to bedside handover.
The results of this study suggest that the research team's evidence-­
based approach to communication training helped nurses recognize
the importance of handover as a critical communicative event and
appreciate their essential role in it (Waters, 2019). Recent reviews on
nursing bedside handover (Anderson et al., 2015), patient participation
in nursing handover (Drach-­Zahavy & Shilman, 2015; Tobiano et al.,
2018) and patient involvement at the micro-­level of healthcare (Snyder
& Engström, 2016) have highlighted the need for specific communica-
tion training for clinicians to foster patient inclusion in their care. Our
communication training helped nurses better appreciate the principles
of patient-­centred care and recognize the benefits of patient inclusion
to quality of care and patient safety. Training in the CARE protocol
gave nurses practical strategies to address the interactional risks in
handover and resulted in more meaningful and useful interactions with
patients and colleagues. Using these strategies helped nurses switch
from talking about patients as if they were not present to, for the most
part, talking with them during handover. Training in the ISBAR protocol
equipped nurses with a structured tool to address informational risks
and helped nurses transfer more complete information in a more logical
sequence, supported by the ISBAR-­structured handover sheet. These
findings are consistent with previous studies investigating use of the
CARE and ISBAR protocols to improve communication during hando-
ver (Pun et al., 2019, 2020; Slade et al., 2018).
In addition to improving communication during handover, our
results suggest that training in conducting bedside handover can ef-
fectively address nurse attitudes towards this practice that function
as a barrier (Tobiano et al., 2017). Consistent with recent research
(Anderson et al., 2015; Manias et al., 2015; Tobiano et al., 2018)
nurses held particular concerns about maintaining patient confiden-
tiality during bedside handover, despite patients not having a strong
preference for how sensitive information is handled (Whitty et al.,
2017). These concerns contributed to a preference for conducting
13652648, 2022, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15110 by Nat Prov Indonesia, Wiley Online Library on [22/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
handover in the corridor, excluding patients from participating in
their care. The observed change in handover location from corridor
to bedside suggests the strategies for handling sensitive informa-
tion and ensuring patient confidentiality taught in the training suffi-
ciently addressed nurse concerns about these issues.
The substantial change we observed in both practice and per-
ceptions of bedside handover cannot be attributed to the commu-
nication training alone, given the recognized challenges in changing
entrenched handover communication practices (McMurray et al.,
2010; Pun et al., 2019). This study's results were likely due to a com-
bination of several factors. First, the design and implementation of
the intervention, which integrated communication training into a
broader suite of ward-­level recommendations to improve handover,
and was tailored to the local organizational, cultural and communi-
cative context (Michie et al., 2011). Second, the ward management's
well-­planned and well-­executed implementation plan combined with
the NUM’s ward leadership (Waters, 2019) was crucial. Previous
studies have emphasized the need for ‘champions’ to achieve and
sustain behavioural change in healthcare settings (Bonawitz et al.,
2020; Dorvil, 2018; McMurray et al., 2010). The NUM championed
change through taking personal responsibility for the intervention's
success, setting clear expectations about handover practices, being
physically present on the ward and accessible to staff throughout
the intervention, and engaging nurses to share responsibility for im-
plementation of the recommendations. Nursing staff met regularly
to provide feedback on implementation, discuss barriers to success
and be involved in decision-­making, which helped facilitate change
in practice. Furthermore, nurses were supported in the transition to
bedside handover (Bressan et al., 2019; Waters, 2019) through the
ongoing, systematic mentoring and modelling the NUM and Clinical
Nurse Educator carried out. This helped actively reinforce and con-
solidate new practices and created a climate where staff felt em-
powered to ask questions and raise concerns.
The numerous recent reviews on nursing bedside handover
are evidence of the multitude of studies investigating different
approaches to nursing bedside handover interventions and their
impact on patient safety, patient and staff satisfaction and patient
participation (Anderson et al., 2015; Bressan et al., 2019; Dorvil,
2018; Gregory et al., 2014; Mardis et al., 2016; Tobiano et al., 2018).
However, it seems that few studies consider the organizational, cul-
tural and linguistic aspects of the local ward context as the basis for
a tailored intervention to improve the patient-­centredness of nurs-
ing clinical handover. In designing and implementing the project in
this integrated way, changing communication in handover practices
to focus on enabling patient inclusion and communicating the min-
imum information content became the impetus for nurses to em-
brace a ward culture that valued patient-­centred care and patient
safety. It seems probable that this will have a positive impact on the
sustainability of the intervention and potentially lead to enhanced
quality of care and patient safety over time.

CHIEN et al.
4.1  |  Limitations
Several limitations apply to this study. First, while small in scale and
based in a single hospital research site with a sample size of three
multidisciplinary team huddles and 19  handover interactions, de-
tailed qualitative analysis of collected ethnographic data provided
meaningful and multi-­dimensional insights into the organizational,
cultural and communicative challenges with ward handover prac-
tices. The small scale ensured that the research team gained an in-­
depth understanding of the local ward context, which was critical
to effective design and implementation of the intervention (Michie
et al., 2011). It also ensured that nursing staff and management could
take ownership of the change process and work closely with the re-
search team to implement the recommendations.
Second, the simultaneous implementation of multiple recommen-
dations (Appendix S1) was necessary to address, in a short time frame,
the systemic factors in the organizational and cultural context of the
ward that impacted on handover delivery and communication; however,
this made it difficult to identify which changes were most effective.
Third, even though the short follow-­up period did not allow
assessment of the longer-­term sustainability of the intervention, a
train-­the-­trainer communication module is being developed and im-
plemented to allow new staff to receive the same communication
in nursing clinical handover training. The practice of mentoring new
staff in using the ISBAR and CARE protocols in their handover prac-
tice will help ensure sustainability.
Fourth, the absence of a comparison group means we did not con-
trol for confounding factors that may have influenced the results. The
limitations described here seem relatively common among studies
aiming to improve handover practices (Mardis et al., 2016, 2017), and
suggest the need for funding for research to measure outcomes over
the longer term, with larger groups and the possibility of comparisons.
5  |  CO N C LU S I O N
Adopting a multipronged approach integrating practical commu-
nication training into broader ward-­level changes to handover
practice tailored to the ward's organizational, cultural and commu-
nicative context resulted in sustainable changes to nursing hando-
ver practices and the ward culture. The intervention enabled nurses
to use the CARE and ISBAR protocols to conduct effective bedside
handovers by simultaneously attending to the interactional and in-
formational dimensions of this complex communicative event. By
actively involving patients and their colleagues during handover
and providing more complete and comprehensive transfer of in-
formation, nurses recognized the value of handover practices in
terms of reducing patient harm. Integrated approaches to improv-
ing communication in nursing handover are likely to be more re-
source intensive in the short term when compared with standalone
communication training as they require committed leadership,
staff collaboration and ongoing mentoring to support successful
implementation. However, the positive impact to both handover
|
13652648, 2022, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jan.15110 by Nat Prov Indonesia, Wiley Online Library on [22/02/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
      1427
practice and ward culture suggests the potential for achieving
more sustainable change. This is an important consideration for
hospitals throughout Australia and internationally as they look to
implement initiatives to improve handover communication to de-
liver enhanced patient-­centred care and patient safety.
AC K N OW L E D G E M E N T S
The research team would like to thank the hospital staff and patients
who participated in this study and the hospital administrators who
supported the research.
C O N FL I C T O F I N T E R E S T
Laura Chien, Diana Slade, Maria Dahm, Bernadette Brady, Liza
Goncharov and Suzanne Eggins declare that they have no conflict of
interest. Elizabeth Roberts, Joanne Taylor and Anna Thornton are em-
ployees of St Vincent's Health Network Sydney. St Vincent's Curran
Foundation, the fundraising group for all St Vincent's hospitals and
facilities in New South Wales, provided funding for the study.
AU T H O R C O N T R I B U T I O N S
All authors have agreed on the final version and meet at least one of
the following criteria (recommended by the ICMJE): (1) substantial
contributions to conception and design, acquisition of data or analy-
sis and interpretation of data; (2) drafting the article or revising it
critically for important intellectual content.
PEER REVIEW
The peer review history for this article is available at https://publons.
com/publon/10.1111/jan.15110.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data are not publicly available and cannot be shared due to pri-
vacy and ethical restrictions.
ORCID
Laura J. Chien  https://orcid.org/0000-0003-2211-0844
Diana Slade  https://orcid.org/0000-0001-6143-5989
Maria R. Dahm  https://orcid.org/0000-0001-8067-4600
Suzanne Eggins  https://orcid.org/0000-0002-1936-0255
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